People with Diabetes Who Live in Rural Areas More Likely to Develop Complications of the Disease, UM School of Medicine Study Finds

They have a significantly higher risk of end-stage kidney disease, heart failure, and heart attacks likely due to a lack of access to medical care.

It has been well established that people who live in rural areas in the U.S. are more likely to have diabetes and experience barriers to managing their condition compared to those who live in the suburbs and cities. Now University of Maryland School of Medicine researchers have measured the devastating toll of this health disparity.

Those who live in small towns experience a significantly higher risk of eight complications related to diabetes – including heart attacks and  kidney disease – failure compared to those who live in well populated suburbs and cities, according to a new study published in the journal Diabetes Care.

The study analyzed health insurance data from nearly 3 million adults with diabetes across the U.S. over a 10-year period through 2021. They found that those living in small towns (population size of 2,500 to 50,000 people) were 10 percent more likely to experience a heart attack, 5 percent more likely to heart failure, and about 4 percent more likely to have end-stage kidney disease compared to those living in larger towns and cities.

“Those who live in rural areas have a greater risk of experiencing 8 out of the 11 complications that we measured compared with those living in cities,” said study corresponding author Rozalina McCoy, MD, Associate Professor of Medicine at UMSOM and Director of the Precision Medicine and Population Health Program at the University of Maryland Institute for Health Computing. “They were 15 percent more likely to have dangerously low blood sugar levels, which clearly indicates that their diabetes is not being managed properly.”

About 14 percent of those in the study lived in small towns, compared to 83 percent who lived in cities. An additional 3 percent lived in remote areas of fewer than 2,500 people living within a defined geographic area in their county.

“While our study didn’t address why these differences exist, we do know that people living outside of city areas are less likely to receive care from diabetes specialists, to receive diabetes self-management education, and to be monitored for diabetes complications,” said study co-author Esa Davis, MD, Professor of Family & Community Medicine and Senior Associate Dean for Population and Community Medicine at UMSOM. “Our research builds on this foundational evidence to demonstrate a possible impact that these differences have on preventable diabetes complications.”

Interestingly, the study found that people living in remote areas had lower risks of being diagnosed with some diabetes complications. They were 15 percent less likely to have dangerously high blood sugar levels and were 6 percent less likely to experience heart failure compared to those living in small towns.

But that may not mean they are actually having fewer complications: Since the study team relied on insurance information to identify diabetes complications, if people were not able to access medical care, that complication would not be captured. Dr. McCoy noted that this finding further underscored the barriers to care in remote areas: patients are likely having high blood sugar emergencies and heart failure but cannot get to the emergency department or hospital to have them diagnosed and treated.

The researchers controlled for age, sex, health insurance type, diabetes type, medication use, and chronic health conditions.

“While the relative risk increases in diabetes complications were modest for those who dwell in rural areas, they can add up to a huge health burden since more than  5 million Americans who have diabetes live in small towns,” said Mark T. Gladwin, MD, who is the John Z. and Akiko K. Bowers Distinguished Professor and Dean of UMSOM, and Vice President for Medical Affairs at University of Maryland, Baltimore. “There is a pressing need to enhance physician and medical provider services and hospital services for those living in rural communities, and we are planning a new program to bring our medical students to Maryland’s rural Eastern Shore to help address this disparity.”

Researchers from the Mayo Clinic and Yale School of Medicine were co-authors of this study. The study was funded by the National Institute of Diabetes and Digestive and Kidney Diseases (grant K23DK114497).

About the University of Maryland School of Medicine

Now in its third century, the University of Maryland School of Medicine was chartered in 1807 as the first public medical school in the United States. It continues today as one of the fastest growing, top-tier biomedical research enterprises in the world -- with 46 academic departments, centers, institutes, and programs, and a faculty of more than 3,000 physicians, scientists, and allied health professionals, including members of the National Academy of Medicine and the National Academy of Sciences, and a distinguished two-time winner of the Albert E. Lasker Award in Medical Research. With an operating budget of more than $1.2 billion, the School of Medicine works closely in partnership with the University of Maryland Medical Center and Medical System to provide research-intensive, academic, and clinically based care for nearly 2 million patients each year. The School of Medicine has more than $500 million in extramural funding, with most of its academic departments highly ranked among all medical schools in the nation in research funding. As one of the seven professional schools that make up the University of Maryland, Baltimore campus, the School of Medicine has a total population of nearly 9,000 faculty and staff, including 2,500 students, trainees, residents, and fellows. The School of Medicine, which ranks as the 8th highest among public medical schools in research productivity (according to the Association of American Medical Colleges profile) is an innovator in translational medicine, with 606 active patents and 52 start-up companies. In the latest U.S. News & World Report ranking of the Best Medical Schools, published in 2023, the UM School of Medicine is ranked #10 among the 92 public medical schools in the U.S., and in the top 16 percent (#32) of all 192 public and private U.S. medical schools. The School of Medicine works locally, nationally, and globally, with research and treatment facilities in 36 countries around the world. Visit medschool.umaryland.edu